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STATE OF CALIFOR0 WATER RESOURCES CONT BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM op TANK PERMIT APPLICATION INFORMATION TANK �_�6MPLETE A SESEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z MARK ONLY ' ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY NK c ONE ITEM ❑2 INTERIM PERMIT ❑ 1 AMENOEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE �ANK REMOV, A FACILITY/SITE NAME WHERE TANK IS INSTALLED: '. -7 FARM TANK-VES NO ❑ (\ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY C CG A. OWNERS TANK ID N B. MANUFACTURED BY: v C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: C'/•� _--' 11. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A• 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM . / C. ❑ I UNLEADED 2 LEADED '1 DIESEL �❑ BE] © 3 CHEMICAL PRODUCT ❑4 OIL 12/1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0 BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 CA.S,N C.A.S.N' 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B,C,A D A.TYPE OF - ❑ 1 DOUBLE WAILED ❑3 SINGLE WAILED WITH EXTERIOR UNEN ❑ 95 UNKNOWN SYSTEM. ❑2 SNGUWALLED ❑1 SECONDARYOONTMNMEM ❑ 99 OTHER ❑1 STEFUMON ❑2 STAINLESS STEEL ❑3 RBERGIASS ❑A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCIE7E YMATERIAL. ❑6 POLYVINYL O LORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FAP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RBBER UNED ❑2 AIKYO UNING ❑ 3 EPDXY LINING ❑ 1 PHENOLIC UNING LINING ❑5 OIASSl9NN0 ❑6 UNLINED ❑95 UNKNOWN ❑ISUNING MATERIAL COMPATIBLE MTN 100%MEDWIOL7 ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I.POLYETIILENEWMP ❑2 TAR ORASPHALi ❑3 YBmwRw ❑ FIBERGLASS REINFORCED PUSTIc PROTECTION;-❑5 CATIIODCPR7TECRGN ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U / FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 6 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANREOSTEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P B 2 INVENTOR/RECONCILIATION P 9 3 VADOSE WELLS P B I ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P B 6 PRECISION TESTING P B 7 PRESSURE TESTING P N 91 NONE P N 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT I BY: J �.;`- FORM B IB-29•BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY751TE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED